Mental health professionals have always understood that the
problems they deal with arise largely in families and take their
form from family relationships. Marriage and family problems
account for about half of all visits to psychotherapists. Families
also play the decisive role in most non-biological explanations of
emotional disturbances and mental illness. Psychodynamic
psychotherapists are concerned with childhood conflicts between
instinctual drives and family prohibitions. Behaviorists and
cognitive psychotherapists emphasize social learning, which also
occurs mainly in the family. Yet for many years mental health
professionals tended to ignore their patients' families. They were
often seen mainly as an obstacle to treatment, although they were
often called on to care for the patient and of course to pay the
bills. More recently, the dominance of biological explanations for
some severe forms of mental illness has also reduced emphasis on
the family's influence.

A major variation in this pattern is represented by family
therapy, which is now about 40 years old. It regards individual
symptoms as family problems and treats the family rather than the
individual. It is not distinguished by any definite set of ideas
about the causes and treatment of emotional disturbances and
mental illness. Some of its concepts and techniques are new, some
are borrowed, and some are unfamiliar outside the field. There are
many varieties of family therapy which may be combined in
different ways with one another and with other types of therapy.

Probably the most important practical innovation of family therapy
is bringing the whole family together for therapeutic sessions, an
arrangement known since the 1950s as conjoint family therapy.
Sessions are often held once a week and may last as long as two
hours. They may be videotaped or observed by consultants and
supervisors in the room or behind a one-way screen. Sometimes two
therapists participate -- usually a woman and a man. Many family
therapists conduct individual therapy at the same time for one or
more members of the family; this is known as concurrent therapy.
Marital or couples therapy is usually considered a branch of
family therapy. Almost all family therapists also see couples, and
many couples therapists from time to time also work with the
family as a whole. For families with a well-defined, long-term,
common problem like schizophrenia or alcoholism, group meetings of
several families may be suggested. These are called multiple
family groups.

SYSTEMS THEORY

If any single idea could be said to guide family therapy, it is
probably the notion of a family system, derived from general
systems theory. Human life can be organized hierarchically into
systems of varying size and complexity: the individual, the
family, the society, the culture. The family is seen as a self-
maintaining system which, like the human body, has feedback
mechanisms that preserve its identity and integrity by restoring
homeostasis -- the internal status quo -- after a disturbance.
Therefore, a change in one part of the family system is often
compensated elsewhere. Families have mechanisms for adapting to
changed circumstances, and, like individuals, they have
biologically and socially determined stages of development. A
family that functions poorly cannot adjust to change because its
homeostatic mechanisms are either inflexible or ineffectual. The
family's daily habits and internal communication -- its
transactional patterns, as they are called -- harm its individual
members. The pathology is in the system as a whole. Individual
disorders not only serve as a source of protection and power for
the disturbed person but may also preserve the family system and
act as a distorted means of communication within that system. They
fulfill the same function that neurotic symptoms are said to
fulfill for individuals in psychodynamic theory.

In family therapy, as in general systems theory, the main concern
is with processes rather than sources and forces. Systems theory
defines influences as mutual and causality as circular, so family
therapists tend to avoid blaming and attributing causes --
although there are exceptions to this as to every other
generalization about the field. The symptoms of a defective family
system are said to take different forms in different parts of the
system. A husband and wife, for example, may seem to have very
different personalities because of their functions within the
system rather than anything intrinsic to them as individuals. For
this reason, family therapists often make limited use of ordinary
psychiatric diagnoses, which describe individual pathology, and
diagnose family situations instead.

Family therapy may of course be a good choice when the family sees
its problems mainly as family problems, but not only then. For
obvious reasons, it is also recommended when the problems involve
children. Some specific situations in which it may be useful are
physical or sexual abuse, chronic misbehavior and delinquency,
eating disorders, and phobias. Family therapy may also help when a
recent crisis has disturbed the family or when the family's
cooperation is needed to help an individual patient. It may be
appropriate when the symptoms of one family member improve in
individual therapy, and another develops different symptoms. (In
fact, family therapy is thought to have originated in the 1940s
when some child psychiatrists noticed that families had to
readjust after children improved in treatment.) Family therapy can
also be useful for alcoholics if they attend Alcoholics Anonymous
meetings at the same time. Controlled studies suggest that family
therapy may be better than individual therapy for eating
disorders, for children's behavior problems, and for preventing
relapse in schizophrenic patients living at home.

One important concept in family therapy is the 'identified
patient,' the person whose symptoms bring the family to a
psychotherapist. Just as psychoanalytic theorists say that
neurotic symptoms maintain individual stability while both
expressing and disguising conflicts within the individual, family
therapists say that symptoms maintain the stability of the family
system while expressing and disguising family conflicts. A
husband's or wife's psychosomatic symptoms 'solve' the problem of
a couple's social anxiety; a rebellious teenager fights his
mother's battles with his father; a wife is sick because it is the
only way to get her husband's attention; the sleep problems of a
12-year-old are sustained by his mother's insomnia, because she
can best cope with her own sleeplessness by comforting him.

FAMILY SYMPTOMS

Family therapists report distinct patterns of family symptoms. In
some cases each partner in a marriage is demanding too much of the
same thing from the other: service, protection, care, etc. In
other cases they compound each other's problems by complementing
each other. One partner takes charge and the other becomes
incompetent: an overbearing and emotionally distant husband has a
'hysterical' wife whose erratic behavior makes him still more
overbearing; a strong, angry wife has a passive, alcoholic husband
who is a suitable object of her anger, and that anger makes him
even more passive; the husband of a depressed and hypochondriacal
woman needs to be a healer and savior. Often family therapy aims
to reveal what is hidden: the passive partner's suppressed anger,
the savior's feelings of helplessness.

A related idea is that of unconscious or unacknowledged roles.
Roles in the drama of family life, assumed perhaps out of loyalty
or a need for belonging, may become destructive yet hard to
abandon because they help to maintain the family. For example, a
child who becomes 'parentified' because of a mother's or father's
incapacity is likely to play this adult role poorly, using
authority too harshly or making it a vehicle of rivalry with
younger brothers and sisters. Another child may be assigned the
role of bad boy so that one of the parents can play
disciplinarian. Such roles must be openly recognized and the
assignments altered if the family is to become more healthy. A
similar idea that some therapists find useful is family mythology:
"John is the stupid one," "Father can't work." These myths, rarely
discussed openly, are especially likely to create conflict when
they are incompatible or not accepted by all members of the
family. The rules and rituals of families are also important; for
example, one researcher found that when drunkenness was part of a
family ritual like the evening meal, alcoholism was more likely to
become a 'tradition' passed on to the next generation. Some family
therapists refer to types of family culture; there are
authoritarian, democratic, and individualistic families, each with
their own typical ways of functioning well or badly.

Family problems may also be seen in terms of an informal contract
with secret and unconscious as well as openly acknowledged
clauses. In bad marriages, each partner may behave as though
certain provisions are accepted when in fact they are not; for
example, a husband believes that his wife has agreed that he can
stay at work as long as he thinks he must; she thinks that he has
implicitly agreed to be home for supper, and they have never
discussed the matter. Some broader implicit contract provisions
are: I need sex, I need financial security, I need to be in
charge, I need a certain number of friends.

FAULTY COMMUNICATION

Family therapists also study faulty communication, verbal and
nonverbal. One distinctive pattern, for example, is invalidation
of another person's feelings: "I am angry." "No, you're not -- you
are not the kind of person who gets angry about something like
that." A well-known type of defective communication is the double
bind. (This idea was developed to explain the origins of
schizophrenia, where it did not prove to be helpful; now it is
used mainly in other contexts.) A double bind exists when one
person sends two mutually exclusive messages to another (usually
one message in words and the other in gesture, tone and
expression), and the second person must not acknowledge the
contradiction or respond to the real message if he or she wants to
maintain a needed relationship with the first person. For example,
a mother asks her son to come to her, stiffens when he approaches,
and then, when he withdraws in turn, says, "Why are you so cold?"
The son is stymied whether he shows his love for his mother or
avoids showing it; and he cannot point out what is going on,
because that would only further alienate her. In another example,
a father says to his child "You are tired; go to bed." By reading
tone, expression, and gesture, the child senses that the
underlying message is "Get out of my sight, I am sick of you." To
acknowledge this would be terrifying, so the child tells herself
that she is tired even when she is not. According to the theory of
double binds, people exposed constantly to this kind of
communication eventually find it hard to say what they mean,
understand what others mean, and distinguish real from simulated
feelings.

SUBSYSTEMS AND BOUNDARIES

Many family therapists view the family as incorporating
subsystems, or functional groups of its members. The spouse
system, consisting of the husband and wife, is a refuge for the
couple and a source of authority in the family. The sibling
subsystem helps children learn to negotiate, compete, and
cooperate with other children. Subsystems that cross generations
may incorporate one parent and the children, one child and the
parents, or a parent and a child. According to family therapists,
subsystems should have boundaries that are neither too rigid nor
too vague, and therefore preserve the integrity of both
individuals and the family. An example of conflict over boundaries
is a struggle between teenagers and their parents over the right
to keep the doors to their rooms closed and choose their own
decoration for the walls; the adolescents see the closed door as a
boundary that protects their independence. In some families the
boundaries between persons and generations are weak and permeable,
and the roles of parents and children are indistinct, but the
boundary between the family and the outside world is too rigid.
Other families have weak external boundaries and are therefore in
danger of becoming too heavily dependent on a therapist.

In a family that functions well, the subsystems have clear
boundaries, especially those between generations. The alliance
between the parents is strong; they support each other in front of
the children and do not allow the children to arbitrate their
disputes. Breaching this boundary can be dangerous. If a parent
forms a coalition with one child against the other parent, the
parental subsystem becomes diffuse. The mother may be very close
to a parentified child, and together they may scapegoat a second
child as the object of their complaints and the victim of their
discipline; the sibling subsystem has lost its boundaries. In
other cases boundaries remain too rigid; for example, a father
loses his job and the mother's income supports the family while
the father is asked to care for the children at home, but the
mother does not grant him the necessary authority. The mother-
child subsystem persists despite changes required by economic
circumstances.

Some families are highly interdependent; everyone in them is
overresponsive to everyone else. They develop habits of intimate
quarrelling and complaining that become difficult to change. In
other families, the family members have little mutual contact or
concern; their boundaries are rigid. Family systems that are too
closely knit, or enmeshed, respond too intensely to change; every
disturbance may turn into a crisis. Systems in which the family
members are distant, or disengaged, do not respond strongly
enough; serious problems are ignored and issues are avoided.

"Triangulation" and "detouring" are ideas related to the notion of
a family subsystem. A triangle is a subsystem of three people in
which two exclude a third; for example, a mother and daughter
forming a coalition against the father. Each parent may compete to
enlist a child in a struggle against the other. The child then
becomes a referee, an ally, a surrogate wife or husband. Torn
between the parents, the child may develop behavior problems or
psychosomatic symptoms. Detouring, or scapegoating, means using
criticism of an outsider to dissipate conflicts within a given
system or subsystem. A daughter who refuses to eat, or a
rebellious son, for example, may be the scapegoat who keeps the
mother and father too busy to argue with each other. The
scapegoat, too, often gains something; the boy may be provoking
fights in order to avoid schoolwork and defend himself against
feelings of inadequacy created by a learning disorder. An idea
that serves as a bridge between psychoanalytic theory and family
systems theory is projective identification. This is a process in
which a person denies responsibility for his own impulses and
attributes them to someone else, provoking behavior and feelings
that convince him he is right. X resents Y but does not
acknowledge the resentment and instead comes to believe that Y
dislikes him. He treats Y accordingly; Y responds angrily and
confirms the hostility. Projective identification is a source of
destructive role-playing. It is common in marriages where one
partner is overcompetent and the other incompetent. One partner
may be implicitly demanding that the other be weak so that he or
she can be strong -- and hate his or her own weakness as
manifested in the other partner.

Often projective identification is mutual and two family members
are in unconscious collusion to maintain it; for example, a wife
agrees to act out her husband's impulses and he agrees to be her
stern conscience. In such marriages the partners both need and
dislike each other. According to psychoanalytic theory, a
relationship with a parent is often reenacted through projective
identification, and husbands and wives may be chosen for that
purpose; for example, a passive wife who has unconsciously
incorporated the anger of her assertive mother projects that
unacknowledged feeling onto her husband, who then bullies her in a
way that she necessarily hates.

PART II

In Part I we discussed the concepts and theories used by family
therapists. This part is devoted mainly to therapeutic techniques.

Family therapists think of families as having stages of
development, like individuals. A couple forms and the partners
separate themselves from their original families. The children
arrive, introducing new subsystems and the need to exercise a new
kind of authority. School-age children learn how other families
are run and may demand changes in their own. Adolescents develop
competing social ties and begin in turn to separate themselves
from the family. Eventually the couple is alone again.

Each stage has its normal problems and crises and each also
produces typical pathological disturbances. While the couple is
becoming established, one partner may form an alliance with his or
her family of origin against the other partner, or, on the
contrary, one set of in-laws may be cut off entirely. As the
children grow up, parents may be unwilling to renegotiate family
rules or permit them a separate identity; for example, a child
develops a school phobia because a parent feels abandoned when the
child leaves the house. Teenagers may be unable to achieve
independence because their emotional problems serve to keep a
troubled family together. Family therapists may interpret such
situations psychoanalytically, assign tasks like behavior
therapists, challenge beliefs like cognitive therapists, offer
practical advice, support and reassurance, teach social skills,
set authoritative limits, or direct the dramatic reenactment of
typical family situations. Some family therapists remain almost as
neutral as psychoanalysts, and others become intensely involved,
trying to sympathize with each member of the family in turn. One
technique used by family therapists is 'joining' the family to
probe for possibilities of change. That might mean using the
family's own language, adopting its tempo of speech, and showing
sympathy by such comments as "I had an aunt like that," or "I also
have two teenagers." It may be necessary to join each family
subsystem in turn, or temporarily become the ally of one family
member against another. The therapist may join a powerless family
member to challenge the hierarchy, or join dominant family members
to provoke a challenge. Thus a therapist might join parents in
opposition to a disobedient child, or the child in opposition to
the parents. The purpose is the same in both cases: to strengthen
the parents' alliance so they will agree to insist that the child
change. Later the therapist can turn to conflicts in the marriage
that are related to the child's problem.

Some issues family therapists consider while observing the family
are: how do the family members group themselves in the office? Who
speaks for whom? Who 'remembers' for the family? Who exercises
authority over the children? Some questions they may ask are:
Which of the brothers and sisters pleases your mother most? What
about this family worries you most? What are your hopes for the
family? In daily life, who is with whom at what times? What does
each of you like most and least about the family? What methods of
discipline are used?

REFRAMING IN THERAPY

Family therapists are often less interested in the problem as it
is presented than in knowing which family members think that a
problem exists and what each of them thinks the problem is.
Sometimes the most important person in therapy is not the
identified patient but the family member who seems most concerned
about the identified patient's symptoms. Reframing is a method
used to draw attention away from the identified patient and in
general to alter the focus. Parents may say "Our son has
tantrums," or "My daughter is disobedient." Through reframing this
is translated into something like "He becomes enraged when his
father tells him to clean up his room," or "She disobeys her
mother when her father is not present." Now the therapist may
discover, for example, that the mother of the disobedient son
thinks her husband should not ask the boy to do what he himself
would not do. More generally, a verbal attack can be reframed as a
way of reaching out for contact; apparent helpfulness may have to
be reframed as restrictiveness; the problem of a child's social
withdrawal may be redefined as the problem of her mother's
depression. A father's apparent inability to talk to his children
may be reframed as his way of being loyal to his wife, who needs
to be closer to the children than anyone else in order to allay
her own anxieties.

ENACTMENT

To get a better idea of how the family behaves outside the office,
the therapist may ask them to enact typical family situations
instead of talking about them. They are told to talk to one
another instead of rehashing old arguments and asking the
therapist to arbitrate. The therapist might even leave the room
for a while. Enactment exposes situations that might otherwise
remain obscure. For example, a wife complains that her husband
talks too little, and in fact he is silent during therapy
sessions. But when they are instructed to speak to each other, it
becomes obvious that she constantly interrupts him. The therapist
can then observe the effect of preventing interruptions and get
further hints about how to work with the family.

Family therapists may also rearrange seating, ask family members
to touch one another, or place a child where he cannot catch a
parent's eye. For example, a family comes to the therapist's
office with the problem of a ten-year-old boy who is truant and
stealing. When they sit down, the boy's mother signals to his
father, and the father begins to talk about his son. As he talks,
the mother watches her son and her five-year-old daughter. After a
while she interrupts her husband and signals her 14-year-old
daughter to begin talking. The therapist, more interested in this
pattern than in what is being said, asks the mother to sit at a
distance from the children in order to see whether the father can
handle them by himself.

Although most family therapists concentrate on the present, some
look for ways in which the past can illuminate it. They sometimes
construct a three-generation 'genogram' which lists all the
relatives of each parent along with their dates of birth and
death, marriages, jobs, health, and other pertinent information.
The therapist refers to the genogram for facts and patterns that
may illuminate the present; for example, the husband is an only
child, or all the women on both sides of the family have married
men who were thought to be not religious enough, or all the
daughters fight with their mothers. Some family therapists send
their patients to visit grandparents or invite grandparents for
therapeutic sessions. These sessions can be remarkably revealing.
Adults may get to know their parents as real people and not
overpowering fantasy figures. The sources of projective
identification may be uncovered. People who are automatically
imitating their parents or still too closely attached to them may
learn how to break away.

Some family therapists are especially concerned with what they
call invisible loyalties and debts incurred between generations.
The therapy involves adjusting ethical claims -- those of each
family member and those of the family as an institution. A
person's understanding of a present family member's claims often
depends on childhood experience, and that may lead to conflict.
For example, a woman whose parents neglected her wants a husband
who will make up for her lost childhood, and he does not
understand this; a man who has been left by his first wife with a
small son considers it his second wife's duty to care for the
child, but she once had to care for her younger brothers and
sisters in a home with an absent father and now believes that he
as a man is in debt to her for taking on the child. Family
loyalties are so powerful as forces to be acted on or acted
against that even in individual therapy interviews with a
patient's or client's family of origin can be effective in
producing therapeutic change.

PRESCRIBED TASKS

Either during therapeutic sessions or as homework, family
therapists may also prescribe tasks that reveal significant
patterns or bring about change. A wife is told to exaggerate her
criticism of her husband until he challenges her. A husband is
told to buy his own clothes and consider only his own taste. A
woman is asked to let her husband put their daughter to bed while
she relaxes. Some of these tasks are simple behavior therapy. When
a husband and wife have been drifting apart, the therapist may
arrange for the husband to come home for dinner five nights a
week. If a 12-year-old tearfully refuses to go to bed, constantly
enters his parents' room at night and will not get out of bed for
school, the therapist may tell the parents to insist that their
son use an alarm clock and say they will punish him if he is late
for school.

BEHAVIOR THERAPY

Behavior therapy works only if family members will do what the
behavior therapist prescribes. But invisible loyalties,
unacknowledged contracts, projective identifications and distorted
communication may make it impossible for family members to think
straightforwardly about what they want and need. In that case
family therapists sometimes suggest a different kind of homework,
meant to unsettle and test the family. The therapist usually
expects failure, and is interested mainly in whether the family
ignores the suggested task, misunderstands it, or tries to comply
but gives up.

When resistance to change is especially strong, the family
therapist may use a method called the paradoxical task, which is
meant to provoke a crisis. The theory is complex, but the general
point is that a paradoxical instruction, if followed, would
achieve the opposite of what the therapist and family want. The
family is expected to defy the order or follow it only until its
absurdity becomes obvious. For example, a mother lives with her
19-year-old son who is socially isolated and suicidal; the family
therapist tells the mother to go everywhere with the son.
Eventually they become exasperated with each other and fight; that
allows the son to achieve more autonomy and eventually to move
out.

Paradoxical tasks may be prescribed when parents are detouring
their conflicts through a child's symptoms and the child is
protecting the parents. For example, an eight-year-old boy is
failing in school. The family therapist sees the problem as the
mother's disappointment with her husband, who is failing in
business while she earns the family income. She avoids arguing
with her husband but nags her son when she becomes annoyed at his
father's apathy. The son in a sense cooperates by providing causes
for complaint. The therapist tells the mother to go on criticizing
her son, because she has to criticize someone and her husband is
too vulnerable because of his depression. The therapist also tells
the son to keep monopolizing his mother's attention. The father
agrees, but the mother indignantly rejects the suggestion that she
should take out her anger on a boy. She and her husband come into
open conflict that offers an opportunity for change.

TREATMENT OF SCHIZOPHRENIA

Many experts once thought that the family environment caused
schizophrenia; now almost all believe that its roots are
biological and partly hereditary. Nevertheless, recent studies
have shown that family therapy or family management improves the
symptoms and reduces the burden substantially. Families can be
educated about the illness without being blamed for it. They are
taught to communicate better with schizophrenic patients, to
reduce their expectations and temper their criticisms of the
patient in recognition of the illness. They can be encouraged to
watch for signs of relapse and hold meetings to discuss serious
problems. Mutual support and advice may be provided through
multiple family groups. Parents can be taught how to enforce rules
of behavior for schizophrenic adolescents. The popularity of
family therapy has grown greatly in the last twenty years, but
those same years have seen the rise of biological psychiatry, new
developments in individual psychology, and increased social
criticism of all forms of psychotherapy. Meanwhile, larger
historical trends have been changing families in unpredictable
ways. The relative influence of all these forces will determine
how important family therapy becomes and what forms it takes in
the future.